1022 Early Cholecystectomy in the Ageing Population

Background

The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy.

Method

Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality.

Results

41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2–5 days) and the median admission to surgery time was 6 days (range 5–12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation.

Conclusion

Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

Immunotransplantation for multiple myeloma using allogeneic peripheral blood stem cell transplantation

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Background: Despite the improvement seen in patients with multiple myeloma (MM) treated with autologous hematopoietic cell transplantation (auto-HCT), most of the patients relapse or die of their disease. The objective of the study was to decrease toxicity of allogeneic HCT for MM patients while allowing the benefit of graft-versus-myeloma effect by using a non-myeloablative HCT (NM- HCT) approach. Methods: Newly diagnosed or previously treated myeloma patients of any stage were enrolled. All patients but one received VAD regimen prior to conditioning regimen which consisted of Fludarabine at 30 mg/m2/day on days -5, -4, -3 and Melphalan at 80 mg/m2 x 2 on days -2 and -1. Graft-versus-host disease (GVHD) prophylaxis included cyclosporine 3 mg/kg intravenously on day -2 and methotrexate at 10 mg/m2 intravenously on days 3, 6, and 11. Results: A total of 8 MM patients (4 IgG, 1 IgA, 1 light chain restriction, 2 non-secretory MM) with a median age of 46 years old (range, 35 to 57 years) have been enrolled. Only one patient received 3 regimens prior to NM-HCT. The initial responses to therapy prior to NM-HCT were: 2 CR, 1 nCR, and 5 PR. All patients received identical 6/6 HLA sibling donor stem cells. All patients but one attained CR (88%) after NM-HCT. The median time for ANC engraftment (≥ 500/mm3) was 12.5 days (range, 10–22 days). Four patients developed acute GVHD grade I-II (3 skin, 1 gastrointestinal); all of them responded well to methylprednisolone treatment. Four patients developed chronic GVHD (grade I-II). The 100-day mortality rate was 12% (1 patient died at day + 96 without evidence of MM). Post-transplant, all patients have reported a Karnofsky’s scale performance status between 80%-100%. Two patients relapsed after 31 months post-transplantation. After a median follow-up of 46 months, median survival has not been reached. Only 1 patient who relapsed has received treatment including auto-HCT. Conclusions: NM-HCT is a feasible treatment option in MM patients with a manageable toxicity profile and acceptable treatment-related mortality. Longer follow-up is needed to evaluate for graft-vs- myeloma effect using this approach.

No significant financial relationships to disclose.

Decreased quality of peripheral blood progenitors collected after a peripheral blood progenitor transplant

The purpose of this study was to determine the quality of peripheral blood progenitor cells (PBPC) collected after an initial autologous PBPC transplant. Tandem autologous transplants have been used in the treatment of several malignancies. Routinely, PBPC have been collected prior to the first transplant and used for both transplants. In the current study, PBPC harvested prior to the first high-dose therapy (HDT) were used as a source of progenitors for transplant 1, and a combination of bone marrow harvested prior to the first course of HDT and PBPC collected approximately 85 days after the first transplant were used to support the second HDT. We analyzed the quality of the PBPC collected 85-120 days after HDT and autologous PBPC transplant. CD34 and colony-forming units granulocyte-macrophage (CFU-GM) contents of those collections were poor, and hematopoietic recovery was more consistent with recovery from a bone marrow transplant than a PBPC transplant. Thirteen of 15 patients received both transplants. Days to absolute granulocyte count of 500 was 10 +/- 1.5 for the first transplant and 13.3 +/- 3.7 for the second (p < 0.01). The number of days to platelet count of 20,000 was 14.3 +/- 10.7 for the first transplant and 18 +/- 7 for the second transplant (p = 0.066). The number of days of total parenteral nutrition (TPN) and intravenous morphine used by patients for the first and second transplants was similar, whereas the length of hospitalization was 21.8 +/- 3.6 for the first transplant and 27.6 +/- 7.8 for the second transplant (NS). In conclusion, it appears that the quality of PBPC collected following a previous PBPC transplant may be compromised.

Distribution of aromatase P450 transcripts and adipose fibroblasts in the human breast

The fibroblast component of adipose tissue is the primary extraglandular site of aromatase P450 (P450arom) expression, which is responsible for the conversion of C19 steroids to estrogens. Previously, we have shown positive correlations between the level of P450arom transcripts and the ratio of fibroblasts to mature adipocytes in adipose tissue samples proximal to breast tumors. The present study was conducted to determine the distribution of P450arom messenger ribonucleic acid (RNA) levels and fibroblast to adipocyte ratios in disease-free breasts of premenopausal women. Adipose tissue samples were collected from 3 regions (outer, upper, and inner) of both breasts of 13 women undergoing reduction mammoplasty. The histological composition of adipose tissue (n = 12) was determined by morphometry using a computerized image analysis program. We used a competitive RT-PCR method employing rat P450arom complementary RNA as an internal standard to quantify adipose P450arom transcripts in tissue total RNA samples (n = 11). Overall, 67% of the highest fibroblast to adipocyte ratios and 64% of the highest P450arom transcript levels were detected in an outer breast region, whereas in only 1 patient were the highest values detected in an inner region. Parametric ANOVA showed significant differences between the fibroblast content of the regions [p(F) = 0.037]. This distribution pattern directly correlates with the most common or the least common sites of carcinoma in the breast, the outer and inner regions, respectively. Moreover, a direct relationship was demonstrated between adipose fibroblasts and P450arom transcripts within the breast, in that regions with the highest fibroblast to adipocyte ratios contained the highest P450arom transcript levels (by ANOVA of contrast variables, P = 0.0009). These results suggest that, similar to our previous findings in the breast bearing a tumor, adipose tissue aromatase expression in the disease-free breast is determined by the local ratio of fibroblasts to adipocytes.